Provider Demographics
NPI:1770817124
Name:VALAYAM, JOSEPH CHACKO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CHACKO
Last Name:VALAYAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSEMON
Other - Middle Name:CHACKO
Other - Last Name:VALAYAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1324 WOODLAND DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2651
Mailing Address - Country:US
Mailing Address - Phone:270-765-5921
Mailing Address - Fax:
Practice Address - Street 1:1324 WOODLAND DR
Practice Address - Street 2:SUITE A
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2651
Practice Address - Country:US
Practice Address - Phone:270-765-5921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45063207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100233450Medicaid